NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have any questions about any part of this notice or if you want more information about our privacy practices at FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC you may contact:

Barry G. Herstik, D.P.M.
370 Grand Avenue
Suite 101
Englewood, NJ 07631
201-816-8778

or

Ivan Herstik, D.P.M.
St. Vincent’s Hospital and Medical Center
36 Seventh Avenue, Suite 501
New York, NY 10011
212-366-1718

I. How FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC Offices May Use or Disclose Your Health Information.

FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC collects health information about you and maintains this information both in a chart and on a computer as part of our medical record. The medial record is the property of FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC, but the information in the medical record belongs to you. FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC is required to protect the privacy of your health information. There are privacy laws that permit FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC to use or disclose your health information for the following purposes:

Treatment: The health information collected by this office will be used solely for treatment that is performed in this office. The information may be disclosed to the patient’s medical doctor and information may be shared with related medical doctors who are directly involved with the patient’s treatment.

Payment: Health information obtained is shared with the patient’s insurance company for purposes of reimbursement for procedures and office visits. The health insurance company requires specific information pertaining to procedures and office visits enabling reimbursement for services rendered by the doctor.

Regular Health Care Operations: This office specializes in the diagnosis and treatment of foot and ankle disorders.

Information provided to the Patient upon Request: The patient’s health information will be provided to the patient upon written request.

Notification and communication with family: The patient’s health information may be shared with family members who are responsible for the well-being of the patient and the patient’s care. This may be a family member, personal representative, and/or a person responsible for their care. An example of disclosure would be in the notification of the patient’s general condition or in the event of death. If they are able and available to agree or object, this office must communicate that they will give the patient the opportunity to object prior to making this notification. If the patient is unavailable or unable to agree or object, your health professionals will use their best judgment in communication with your family and others.

• Required by law: As required by law, we may use and disclose your health information. Some examples of these requirements are listed below:

• Public Health: As required by law, we may disclose your health information public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
• Health oversight activities: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclosure of health information to the health agencies during the course of audits, investigations, inspections, licensure and other proceedings.
• Judicial and administrative proceedings: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information in the course of any administrative or judicial proceeding.
• Law enforcement: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
• Deceased person information: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information to coroners, medical examiners and funeral directors.
• Organ donation: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
• Research: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board or Dr. Herstik’s privacy board.
• Public safety: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
• Specialized government functions: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information for military, or national security purposes.
• Worker’s compensation: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may disclose your health information as necessary to comply with worker’s compensation laws.
• Communications: FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC may contact you to provide appointment reminders.
• Change of Ownership: In the event that this office is sold or merged with another organization, your health information/record will become the property of the new owner.

II. When FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC May Not Use or Disclose Your Health Information.

Except as described in this Notice of Privacy Practices, FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC will not use or disclose your health information without your written authorization. If you do authorize FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

III. Your Health Information Rights.

• You have the right to request restrictions on certain uses and disclosures of your health information. Dr. Herstik is not required to agree to the restriction that you requested.
• You have the right to receive your health information through a reasonable alternative means or at an alternative location. (These request should be in writing as to the specific method and payment for the methods)
• You have the right to inspect and copy your health information.

• You have the right to request that FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC amend your health information that the patient feels is incorrect or incomplete. FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC is not required to change your health information and will provide you with information about his review and denial process and how you can disagree with the denial.
• You have the right to receive an accounting of disclosures of your health information made by FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC, except for the disclosures described above for treatment, payment, healthcare operations, information provided to you, directory listings, and certain government functions described within this Notice of Privacy Practices.
• You have a right to a paper copy of this Notice of Privacy Practices.
• If you would like to have more detailed explanation of these right or if you would like to exercise one or more of these rights, contact:

Barry G. Herstik, D.P.M.
370 Grand Avenue
Suite 101
Englewood, NJ 07631
201-816-8778

or

Ivan Herstik, D.P.M.
St. Vincent’s Hospital and Medical Center
36 Seventh Avenue, Suite 501
New York, NY 10011
212-366-1718

IV. Changes to this Notice of Privacy Practices.

FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC is required by law to comply with this Notice of Privacy Practices.

V. Complaint.

Complaints about this Notice of Privacy Practices or how FOOTDRX, LLP, Associated Foot & Ankle Specialist and Medical Partners, LLC handles your health information should be directed to:

Barry G. Herstik, D.P.M.
370 Grand Avenue
Suite 101
Englewood, NJ 07631
201-816-8778

or

Ivan Herstik, D.P.M.
St. Vincent’s Hospital and Medical Center
36 Seventh Avenue, Suite 501
New York, NY 10011
212-366-1718

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201